NTSB meets Metro board

Metro board members and members of the National Transportation Safety Board are lined up across the Metro board room in downtown Washington to talk about the safety panel's recommendations.

"Safety is the top priority at Metro," said Metro board Chairman Peter Benjamin in welcoming them. He says the board intends to ensure "to the best of our ability ... that every recommendation of the safety panel is implemented."

NTSB Chairman Deborah Hersman began her remarks with a review of the safety findings. She refers to the Metro board's lack of oversight. Once again, we see the NTSB investigators' animation of the June 22, 2009, Red Line crash.

Board members stare at the animation in silence at the animation,, as a train under automatic control approaches a stopped train that the system's electronics can't see, and finally crashes into it, killing nine .

Benjamin: "Those of us hear at Metro lost our innocence." It as a time when we could no longer claim we were the safest system in the country if not the world. That's why we would like to talk to you today. We don't want anything like that to come close to happening again.

That said, this board's oversight of safety was ineffective. If accidents like this happen there is something more we need to be able to do. We as a board have often been criticized for being micromanagers and getting too far into the detail.

It would appear to me that your recommendation seems to go in the opposite direction but it isn't absolutely clear what we should be doing differently.Tell us more about the balance: How we should get more into review without micromanaging?

Safety board members discussed their definition of a "safety culture" how an organization can lose it and get it back. The safety board report said that Metro had lost it, from top to bottom

3:10 update
While the NTSB report ripped the transit authority on fundamental failures to protect riders, the face to face exchange today is polite and business like. Metro board members are asking specific questions about ways the organization can improve. The federal officials give specific, workman-like responses, about how a safety culture can be built.

Metro board member Mortimer Downey, one of the federal representatives: I want to be a real partner in moving the organization ahead toward a safety culture. How can the board be effective in carrying that out?

Hersman: Noted that the Federal Transit Administration could provide a bit of a safety net for all transit agencies by developing safety standards for transit equipment and personnel.

"We do expect you all ... to hold the operations accountable to the findings of those other independent audits" from outside safety organizations.

NTSB member Robert Sumwalt: There's no mention of safety in Metro's charter.

Downey: That should be changed immediately.

Sumwalt: "Safety needs to be managed like a vital business function." He suggested that the board divide safety from customer service and operations considerations, forming a separate board committee.

3:20 p.m.
Benjamin: What do we do about the 1000 Series cars, which the NTSB says are not crash-worthy and should be removed from the fleet?

Hersman: The 1000 Series cars represent a risk to the traveling public. You have to manage many factors and safety is one of those. We look only at safety issues. We know there are risks inherent in every mode of transportation. The crash-worthiness is the last piece of this. You want to avoid having a crash in the first place.

Metro board member Chris Zimmerman: Asked for clarification about what exactly went wrong with Metro's automated system.

3:35 p.m. update
Hersman: Went to the NTSB slide presentation, showing the technicalities of a track circuit. But she moves away from technology into the performance of the personnel. It was within Metro's grasp to identify the problem that caused the accident and prevent it, she said. For example, an advanced way of checking track circuits for flaws had been identified by Metro, but was not used consistently before the crash.

[Board members continue too ask the safety officials about best practicies in the transit industry. What models should they follow? Hersman repeatedly noted that the NTSB, by its nature, is not investigating systems that performed well. The investigators go in when something went very wrong.]

3:45 p.m.
NTSB Vice Chairman Christopher Hart: The Metro board needs to create an environment in which employees regularly, voluntarily report problems. This is not the same as a whistle-blower system. In fact, the existence of a whistle-blower system may be an indication of a flaw in the safety culture, suggesting that employees do not feel free to routinely report problems without fear of retribution.

3:50 p.m. update
Metro board member Elizabeth Hewlett: Noted that she watched the crash animation with a heavy heart, thinking, Oh, my goodness, this is what the train operator saw. Safety was always our priority, she said, but we have to live it, we have to breath it. "There will be no deaf ears anymore."

4 p.m. update
Benjamin: We did used to have a board safety committee, he said in response to the safety officials' recommendation that the Metro board have a stand-alone safety committee. The board will recreate the board safety committee, he said.

He continued to detail steps that the staff and the board have been taking during the past year to improve safety, including a safety hotline for employees and a revision of safety operating procedures and replacement of the 1000 Series cars, which fared so poorly in the crash. Benjamin turned to Interim General Manager RIchard Sarles, who made a statement to the NTSB about Metro's recent actions.

4:15 p.m. update
Sarles: Staff is ready to implement the NTSB recommendations on safety. The chief safety officer will report to the Metro board monthy on safety issues. Metro is replacing the track circuit modules and improving its inspection program. He continued to review specific NTSB recommendations and Metro's efforts at compliance. Sarles noted that Metro recently signed a contract to begin replacing the 1000 Series rail cars. An plan is in development to place on-board event recorders on the rail cars that don't have them now.

Metro board member Jim Graham: He began what so far has been the most impassioned and personal remarks about the crash and the board's responsibility. He noted that he was board chairman at the time of the crash. The graphic displays bring it all back, he said.

As other board members did, Graham talked about the difficulty of replacing the 1000 Series cars as fast as the NTSB wanted, and they wanted.

At the core of the June 22 accident, he said, was a technology failure. At that time, no one knew about this failure. The people who had repaired the circuit didn't know, the board didn't know, no member of management knew.

"I think this board needs to be accountable and I want to be accountable as a member of this board," he said. But he repeated that the June 22 crash was a technology failure.

"You say to yourself, What could I have done differently?" Graham said. "What could you have done about this circuitry test?"

"I conclude that I don't know what I could have done." He talked about his efforts to get more money for Metro to upgrade it's equipment.

"As I look back on June 22, I 'm not sure there was anything I could have done based on what I knew."

Hersman: "The right question to ask is not what you could have done, but what are you going to do."

"If you start hearing what sounds like, "We're already doing that stuff," then we're in real trouble. If you hear them say, "We're putting safety first," then we're only so-so -- they've been saying that for years."

I wonder why the NTSB's animation web page says the accident happened in 2010. The Post seems to have carried the error online:
http://www.washingtonpost.com/wp-dyn/content/video/2010/07/27/VI2010072704144.html

Metro needs to appoint a Safety Director. Load that person with a bunch of employees who create a list of major issues and some of the associated sub-issues. Estimate the cost and time to implement these. Do all this within 30-60 days.
Re-assign most of the employees, leaving a staff to manage the on going list.
Then start implementing it. Knock out some of the quick fix items while starting on the longer ones.
Track maintenance, car maintenance, etc all report to the Safety Director.
I would even share at least some of this with the public, let them know what you are DOING to improve the service.

Dr. Gridlock: DragonofAnger, this is a new experience for me. No one ever remembers what I wrote. The Grid Spouse couldn't have come up with that quote from a previous column.

I would rate this session as so-so +. The get the extra mark for the reason NTSB Chairman Deborah Hersman stated after the meeting: "I heard clearly today that they are asking the question: 'What can we do?'"

The board members' statements were rarely defensive. Most focused on specific, practical questions about what went wrong and what the board could do to fix it.